Investing in trained midwives across Liberia

May 2016

Midwifery Liberia
WHO/Liberia

Although 20 years have passed since the first time Bentoe Tehoungue assisted a woman to give birth in rural Liberia, she remembers the experience like it was yesterday.

The pregnant woman was only 13 – an age when childbirth can be a death sentence for both the mother and baby.

“I kept thinking this child should have been in school, not giving birth to a baby,” recalls Bentoe, now a WHO midwife in Liberia.

Since the girl’s pelvis was narrow and underdeveloped, an episiotomy was needed to ensure the baby could be delivered safely. As a result, a healthy 6-pound baby boy arrived with no complications.

But, the mother and baby were lucky.

They had help from a trained midwife — a luxury that many women in rural Liberia may not have. Bentoe also provided the mother with post-natal care and education about delaying future pregnancies until she was physically and mentally ready.

Delivering with more skilled help

In Liberia, about 44% of women give birth at home without a skilled birth attendant, putting them at risk of dying if there are any complications.

Nearly 1 in 138 live births result in a mother dying from preventable causes such as haemorrhage, sepsis or other reasons related to limited access to either basic midwifery or emergency obstetric care, such as caesarean sections. The lack of trained midwives in most rural health facilities and the long distances women have to travel to access care are hindering the country’s progress in reducing maternal and newborn mortality.

Today, Liberia has less than 200 trained midwives for more than 4 million people. And most of those are working in urban areas - compounding the situation for rural women. Nationwide, there are only 2 specialists in obstetrics and gynaecology and 2 in paediatrics. This is partly a result of the 14-year civil war and the Ebola crisis, which left health facilities in disrepair and drove health workers out of the country.

“To help save more women’s and babies’ lives, we need more trained midwives,” says Bentoe. “We need midwives who can ensure a safe pregnancy even before a woman is pregnant. People who can provide advice on family planning, nutrition, physical activity and preventing mother-to-child transmission of HIV.”

To improve access to quality midwifery care, the Liberian Ministry of Health and Social Welfare, WHO and other partners are working to strengthen the country’s 6 midwifery schools, 3 of which are located in rural areas.

Meeting their needs

Beyond training midwives, Liberia is working to retain them. At present, many midwives in the country lack safe accommodation and transport, are overworked and paid poorly, and have limited opportunities for career advancement.

A new Bachelor of Science midwifery programme is providing further professional development to help midwives advance their careers, and can graduate 50-75 registered midwives each cohort, which will help staff more than 700 health facilities in the country.

In order to have a successful degree programme, Liberia is also working to build its teaching faculty. To do so, the country is working with the Danish Midwives Association to “twin” Liberian midwives with Danish midwives so that they can develop skills in advanced level midwifery care, such as methods to prevent and treat haemorrhages. With funding from Sida, the H6 partnership (WHO, UNICEF, UNFPA, UN Women, UNAIDS and the World Bank) is also providing support to these training institutions.

“Strengthening midwifery is essential to the provision of high-quality maternal and newborn care for all women and newborn babies worldwide, and is critical to the implementation of the Global Strategy for Women’s, Children’s, and Adolescents’ Health,” says Dr Anthony Costello, WHO Director, Department of Maternal, Newborn, Child and Adolescent Health.

In addition, WHO with its H6 partners UNAIDS, UNFPA, UNICEF, UN Women and the World Bank, is working to strengthen all aspects of providing quality care, including increasing the provision of antibiotics and family planning supplies, supporting community groups to prioritize their maternal and child health needs, and increasing access to water and sanitation in health facilities.

The work in Liberia is part of WHO’s global effort to provide countries with the guidelines, tools and evidence base to strengthen midwifery so that care can be improved and maternal and neonatal mortality rates can be reduced.